5. Kotze JM, Brits H, BA boots. Forensic documentation: South African Police Service forms, Department of Justice forms and patient information. S Afr Fam Pract. 2014;56:16–22. The second general trap of documentation can be described as a sound trap. As a record of professional activities, the recording must maintain a professional tone. This means that sarcasm, humiliating terminology, jokes, or even an overly casual tone can cast a bad light on the clinician. No joke that could have been humorous in the nursing ward is ever funny when read on the witness stand during a cross-examination trial. Remember that the average jury understands very little about mental health care and may project their fear and aversion to the mentally ill onto the clinician.
If the clinician seems to play this image through the negative tone of protocol entries, it is difficult for the jury to support the idea of attentive, professional and objective care dedicated to the well-being of the patient. 2. Provide justification for patient care. Insurers increase their demand for proper documentation of patient treatment and often refuse to pay for medical services that they believe are not properly documented (need or application). This is especially true for peer reviews, where the investigator regularly justifies their reduction in your bill by commenting on your lack of proper documentation for your treatment. This is no longer enough if your patient only suffers. Your medical records should detail and reflect the objective results of the physical examination that support your patient`s claims and your specific treatment. There are several reasons why this essential element of documentation is useful in liability prevention.
First, clinical judgment itself is the exact opposite of negligence, one of the critical elements of misconduct. In addition, the exercise of clinical judgment is based on objective and subjective clinical factors resulting from the actual encounter with the patient; No one else has had this direct experience with the patient. To take advantage of the immediacy of these observations, it is important to identify the decision-making process that goes into this treatment decision. There are actually three types of stories that are needed in the forensic process. First, the story of the event that brought your patient to your clinic. This includes details of the car accident or other cause of damage. Keep in mind that the legal trail becomes very bumpy if the lawyer only has to rely on the medical record of “Car Wreck” as the cause of injury! b. What objective signs were present that day that indicated the need for treatment? 7.
Haridas SV, Pawale DA. A retrospective study of the model of clinical forensic cases registered at the Kolhapur District Tertiary Health Centre. J Forensic Med Sci Law. 2014;23:1–5. Effective drafting of the MLR will provide insight into how critical the violation is and its significance, and will assist law enforcement agencies in conducting further investigations and making decisions. Forensic documentation includes the overall documentation of the clinical aspects of a case and the information required by the courts.5 Documentation of the injury can include the type, size, location, direction of injury, age of injury, as well as recovery time and direction of injury.5 Therefore, an MPR is crucial because it provides the courts with meaningful written evidence from the medical expert. False or incomplete reports can lead to a pause or delay in the trial and victims` rights can be violated.2 The most common errors in MLR are misidentification of external traumatic injuries, lack of documentation, and state of consciousness.2 Documentation of the nature of the injury and its description helps to infer the causal weapon or pathogen. For example, abrasions, bruises and lacerations are caused by blunt force, while incised wounds are caused by sharp force.6 Our forensic team consists of physicians, physiotherapists, nurses, lawyers and life science graduates. A disciplined team understands the weaknesses of the legal and medical system and prioritizes the privacy of the parties involved. We count success not in winning customers, but in winning the heart of the customer. 1.
Brahmankar TR, Sharma SK. A study based on records of the frequency and profile of forensic cases reported at a tertiary care hospital in Miraj. Int J Community Med Public Health. 2017;4:1348–1352. doi:10.18203/2394-6040.ijcmph20171374 Writing more is not the solution; Simple writing with greater efficiency reduces the time required for documentation. The key to this approach is to keep in mind the three sovereign principles of documentation, which are also very similar to the three principles of medical decision analysis.